California Licensed Documentation Specialist

Job Summary

To enhance clinical documentation accuracy and compliance, the full-time California Licensed Documentation Specialist will review medical records, assign medical codes, and support documentation improvement initiatives while working remotely.

Key responsibilities:

• Review a moderate caseload of medical/health records to ensure accuracy and completeness of clinical documentation
• Conduct staff training and education on clinical documentation improvement and regulatory compliance
• Collaborate with cross-functional teams to identify and implement documentation improvement initiatives

Required qualifications:

• Minimum two (2) years of experience in an inpatient acute care or clinical setting
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field, or equivalent experience
• California Physician Assistant License, Doctor of Medicine License, Nurse Practitioner Certificate, or Registered Nurse License required at hire
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, or case management, or seven (7) years of related experience